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ABSTRACT Background Aims Methods Results Conclusions The accuracy of current criteria for ruling out large oesophageal varices (LEV) and other endoscopic lesions of portal hypertension (PH) may be compromised by obesity and MASLD/MASH.In the US multicentre SHUNT‐V study, we evaluated the disease severity index (DSI) for detecting LEV and other lesions of PH at endoscopy.Subjects were adults with compensated cirrhosis scheduled for endoscopy to screen for varices. DSI was calculated from clearances of labelled cholates after oral and intravenous administration. DSI ≤ 18.3 was evaluated as a cut‐off for ruling out LEV with acceptance criteria of negative likelihood ratio < 0.52 and sensitivity > 85%.SHUNT‐V enrolled 306 subjects; 275 had both DSI and endoscopy, and 238 had Child–Pugh A cirrhosis (52.1% MASLD/MASH, 25.2% chronic hepatitis C and 15.6% alcoholic liver disease; 87% were overweight, 64% were obese and 54% had diabetes). AUROCs for DSI ranged from 0.81 to 0.82 for LEV and 0.79 to 0.80 for all significant PH lesions. DSI 18.3 had sensitivity 96.3%–100% for LEV and 97.3%–100% for all significant PH lesions. If DSI ≤ 18.3 were used as the sole determinant to defer EGD, 27%–35% of EGDs could have been avoided with 0%–3.7% of LEV and 0%–2.7% of all significant PH lesions missed.HepQuant DSI predicts the likelihood of LEV and significant PH lesions across a spectrum of patient characteristics and disease aetiologies. DSI, based on liver function and portal‐systemic shunting, can aid in the decision to defer endoscopy for varices in patients with Child–Pugh A cirrhosis.Trial Registration: The SHUNT‐V study was registered at ClinicalTrials.gov (NCT03583996) [ABSTRACT FROM AUTHOR]

Background: This study aimed to compare the diagnostic efficacy of Two-dimensional shear wave elastography (2D-SWE) with that of transient elastography (TE) in predicting the risk of esophagogastric varices and histological staging in patients with primary biliary cholangitis (PBC). Methods: This single-center prospective study enrolled the patients with PBC diagnosed by liver biopsy following 2D-SWE and TE. Receiver operating characteristic (ROC) curves were constructed for SWE-liver stiffness measurement (LSM) and TE-LSM to assess their diagnostic efficacy for histological staging ≥ stage 2, ≥ stage 3, and = stage 4. The diagnostic efficacy and accuracy of SWE-LSM were compared with those of the Baveno VI criteria for detecting esophagogastric varices. Additionally, the impact of different laboratory parameters on SWE-LSM was analyzed. Results: We evaluated 77 patients (median age, 52 years (range: 16 − 75 years), 66 females). ROC curves constructed using TE-LSM and SWE-LSM demonstrated similar diagnostic efficacy for histological staging ≥ stage 2 (area under the curve [AUC]: 0.824 vs. 0.823 for TE-LSM and SWE-LSM, respectively, p = 0.9764), ≥ stage 3 (AUC: 0.918 vs. 0.907 for TE-LSM and SWE-LSM, respectively, p = 0.6443), and = stage 4 (AUC: 0.907 vs. 0.902 for TE-LSM and SWE-LSM, respectively, p = 0.8763). Additionally, while there was no significant difference in the diagnostic efficacy between the two methods for detecting esophagogastric varices (Z = 1.516, p = 0.1296), 2D-SWE had a slightly higher diagnostic accuracy than TE (61.8% vs. 76.4%). Transaminases and bilirubin levels had little influence on SWE-LSM. Conclusion: 2D-SWE exhibited comparable performance to TE in predicting the risk of esophagogastric varices and histological staging. [ABSTRACT FROM AUTHOR]

Background: Radical cystectomy is typically recommended for managing bladder cancer, with ileal conduit diversion being a prevalent form of urinary diversion. Stomal variceal haemorrhage is a rare complication of ileal bladder diversion and poses diagnostic and therapeutic challenges that can escalate to life-threatening circumstances. Hepatic cirrhosis and cancer liver metastasis-induced portal hypertension are considered the main causes of stomal varices. However, the real-world expertise in the pathophysiology of, diagnostic approach to, and overall management strategy for stomal variceal haemorrhage in ileal conduit diversion is limited. Case presentation: Herein, we present a rare case of a 77-year-old man with bladder cancer who developed stomal variceal haemorrhage after undergoing radical cystectomy and ileal conduit urinary diversion. Imaging revealed that the peristomal varices communicated with the subcutaneous veins of the abdominal wall without apparent portal hypertension. Transhepatic coil embolization of bleeding stomal varices was successfully performed via a transhepatic antegrade approach. No complications or stomal variceal haemorrhage occurred during a 6-month follow-up period. Conclusion: Transhepatic coil embolization may be considered an initial therapeutic option for patients who experience stomal variceal haemorrhage. Comprehensive management of underlying liver disease and portal hypertension is needed at follow-up visits. We describe successful experience with the precise treatment of this rare and atypical disease, conduct a thorough review of the pertinent literature, and deliberate on optimized diagnostic and therapeutic procedures. [ABSTRACT FROM AUTHOR]

The editorial discusses the dilemma of discontinuing non-selective beta-blockers (NSBBs) in advanced liver cirrhosis, with conflicting evidence on the optimal timing. Studies have shown that NSBBs may have deleterious effects in certain populations with cirrhosis, particularly those with higher Model of End-Stage Liver Disease (MELD) scores. The editorial highlights the need for more research to determine the appropriate timing to discontinue NSBBs in cirrhotic patients. The study has some limitations, including a retrospective design and a focus on Chinese patients, which may limit the generalizability of the findings. [Extracted from the article]

Objective: The aim of our study was to evaluate the indocyanine green (ICG) retention test as a noninvasive marker of esophageal varices(EV). Methods: The clinical data of patients diagnosed with compensated liver cirrhosis in Tianjin Second People's Hospital between January 2018 and January 2021 were analysed with SPSS 23.0. Result: A total of 144 patients (88 M/56 F, 51.7 ± 11.06 years) were enrolled. The ICG retention at 15 min(ICG-r15), PVD, TBIL, Cholinesterase(CHE), AST to ALT ratio(ARR), APRI, splenic area, Lok index, Park index and liver stiffness measurement in the absent or small EV group were lower than those in the medium or large EV group, while the ICG disappareance rate(ICG-K), Effective hepatic blood flow(EHBF), ALB, PLT, and Platelet to Spleen Diameter Ratio(PSDR) were higher, and the differences were significant (P < 0.05). ICG-r15, splenic area, APRI and PLT were independent predictors for medium or large esophageal varices (OR = 1.115, 1.025, 0.281, and 0.987, respectively,P < 0.05). The predictive value of ICG-r15 for medium or large varices was 17.95%, the specificity was 0.849, and the sensitivity was 0.662, the AUROC was 0.815. The cut-off value of PLT for M/L EV was 113.5, and the specificity and sensitivity were 0.616 and 0.887, the AUROC was 0.759. The AUROC of ICG-r15 combined with PLT was 0.866, which was more superior than others. Conclusion: Although we are far from the replacement of endoscopy, ICG-r15 combined with PLT seems to be able to identify patients with medium or large EV in patients with compensated liver cirrhosis. [ABSTRACT FROM AUTHOR]

Aim: Advanced fibrosis has a strong influence on the occurrence of liver‐related events in patients with metabolic dysfunction‐associated steatotic liver disease (MASLD), while diabetes mellitus (DM), which is often complicated by MASLD, is associated with the progression of MASLD. We stratified patients with MASLD according to the severity of liver pathological findings and the presence of DM, aiming to examine whether these indices could be used to accurately assess the risk of developing liver‐related events. Methods: A total of 282 patients with liver biopsy‐proven MASLD were included. Liver‐related events were defined as the occurrence of hepatocellular carcinoma (HCC) and complications of liver cirrhosis, such as ascites, hepatic encephalopathy, Child–Pugh class B and C, as well as treatment‐eligible esophageal and gastric varices. Results: Multivariate analysis adjusted for age, sex, body mass index, alanine aminotransferase, creatinine, hemoglobin A1c, smoking habits, dyslipidemia, hypertension, nonalcoholic fatty liver disease activity score (NAS), or fibrosis stage showed that advanced fibrosis with or without DM was a risk factor for liver‐related events. The combined effect of DM and advanced fibrosis increased the risk of HCC onset. However, DM alone or in combination with NAS did not affect the development of liver‐related events, including the occurrence of HCC and complications of liver cirrhosis. Conclusions: While the assessment of fibrosis in patients with MASLD is important for evaluating the risk of developing liver‐related events, combining the assessment of DM may be possible to stratify groups at higher risk of developing HCC. [ABSTRACT FROM AUTHOR]

PURPOSE This meta-analysis aimed to evaluate the diagnostic accuracy of computed tomography (CT) for detecting gastroesophageal varices (GEVs) and identify high-risk GEVs in patients with cirrhosis. METHODS A comprehensive search of databases identified 28 studies reporting on CT-based diagnosis for GEVs confirmed via endoscopy. Meta-analyses were conducted to calculate pooled sensitivity (SEN) and pooled specificity (SPE), positive likelihood ratio (PLR) and negative likelihood ratio (NLR), diagnostic odds ratio (DOR), and the area under the curve (AUC). RESULTS Based on the number of patients (or varices), the pooled SEN, SPE, PLR, NLR, DOR, and AUC of CTbased diagnosis were estimated at 0.91 (0.92), 0.81 (0.45), 4.82 (1.67), 0.11 (0.17), 42.47 (10.26), and 0.93 (0.94), respectively, for any GEV and at 0.89 (0.89), 0.90 (0.79), 8.86 (4.28), 0.12 (0.14), 75.71 (30.19), and 0.95 (0.85), respectively, for high-risk GEVs. Subgroup analyses indicated that CT had a higher diagnostic accuracy for esophageal varices compared with gastric varices (AUC: 0.93 vs. 0.89, P < 0.05), and the 64-slice CT yielded superior SEN compared with 16-slice and <16-slice CT (AUC: 0.97 vs. 0.92 and 0.82, respectively, P < 0.05). Prospective studies demonstrated higher diagnostic accuracy than retrospective studies (AUC: 0.95 vs. 0.90, P < 0.05). Regarding variceal size, a cut-off of 3 mm and 5 mm discriminated between low- and high-risk individuals, respectively, with high diagnostic accuracy (AUC: 0.992 vs. 0.997, P > 0.05). CONCLUSION CT demonstrates promising diagnostic accuracy for identifying gastroesophageal varices and distinguishing high-risk GEVs in patients with cirrhosis. Further research to validate optimal variceal size cut-offs is warranted to enhance clinical utility. CLINICAL SIGNIFICANCE Such a high diagnostic accuracy of CT scans for predicting varices is clinically meaningful for patients with cirrhosis accompanied by portal hypertension. If high-risk varices are identified at CT scans, early intervention would be helpful to reduce the risk of variceal bleeding. [ABSTRACT FROM AUTHOR]

Background: Post-endoscopic variceal ligation (EVL) ulcers represent a complication following EVL, with potential implications for mortality in cirrhotic patients. Prophylaxis against this complication typically involves either a proton pump inhibitor (PPI) or sucralfate. Limited studies have explored the combination of PPI with sucralfate suspension in the prevention of post-EVL ulcers. Objective: The present study aimed to assess the efficacy of the combination of omeprazole and sucralfate suspension in comparison to omeprazole alone for preventing post-EVL ulcers in cirrhotic patients classified as Child-Turcotte-Pugh (CTP) A or B. Materials and Methods: Conducted from March 2019 to December 2022, this prospective, single-center, randomized controlled trial enrolled patients diagnosed liver cirrhosis CTP A or B with esophageal varices. Systematic randomization assigned patients to either the omeprazole plus sucralfate suspension group or the omeprazole alone group. Subsequent esophagogastroduodenoscopy (EGD) was performed two weeks later to evaluate EVL ulceration using Jamwal's classification and complications. Results: Out of the 84 initially enrolled patients, 2 in the omeprazole group were lost to follow-up. Intention-to-treat analysis (82 patients) revealed no significant differences between the combination of omeprazole plus sucralfate suspension and omeprazole alone groups in terms of EVL ulcer type (1 (2.4%) vs. 3 (7.5%) in type C, 40 (95.2%) vs. 35 (87.5%) in type D ulcer; p=0.41), EVL ulcer numbers (4.4±2.0 vs. 4±2.1; p=0.43), and percent decreasing of EVL ulcer numbers (33.3±35.8 vs. 35.7±28.8: p=0.47). No statistically significant variations in post-EVL complications were observed between the two treatment groups. Conclusion: The present study indicates no discernible differences in post-EVL ulcer type, EVL ulcer numbers, percentage reduction in EVL ulcer numbers, and complications between the combination of omeprazole plus sucralfate suspension and omeprazole alone. [ABSTRACT FROM AUTHOR]

Key Clinical Message: The occurrence of terlipressin‐induced skin necrosis in cirrhotic patients is a rare but serious adverse event that warrants further investigation. Clinicians should be aware of this potential complication in cirrhotic patients receiving terlipressin therapy and closely monitor for any signs of skin necrosis. Early recognition and prompt intervention are crucial in preventing further complications and improving patient outcomes. Further research is needed to better understand the risk factors associated with terlipressin‐induced skin necrosis and to develop effective preventive strategies. Overall, healthcare providers should exercise caution when prescribing terlipressin to cirrhotic patients, weighing the potential benefits against the risks of this rare but significant adverse event. Terlipressin is commonly used to manage conditions related to portal hypertension, such as hepatorenal syndrome and esophageal variceal bleeding. Despite its therapeutic benefits, terlipressin can rarely lead to severe ischemic complications involving the skin vasculature, known as terlipressin‐induced skin necrosis. We present a 50‐year‐old male with cirrhosis and acute variceal bleeding who developed skin necrosis following terlipressin administration. We performed a comprehensive review of the literature by analyzing 18 case reports/case series comprising 22 cirrhotic patients with terlipressin‐induced skin necrosis. Among these individuals, we found a mean age of 51 years with a male predominance (78%). Further analysis showed that the onset of skin necrosis ranged from 2 to 5 days post‐terlipressin initiation, with bolus administration being predominant (85.7%). The underlying pathophysiological mechanisms of terlipressin‐induced skin ischemia are still elusive but primarily attributed to the vasoconstrictive and thrombogenic effects. Management involves terlipressin discontinuation and supportive care. Physicians should be aware of this potential complication in patients receiving terlipressin and closely observe for any signs of skin rash. [ABSTRACT FROM AUTHOR]

Background: Cirrhosis is a severe, chronic irreversible condition characterized histologically by regenerative nodules surrounded by fibrous bands in response to chronic liver injury. The objectives of this study were to analyze the clinical profile of the patients admitted with cirrhosis of the liver and to determine the factors affecting the outcome. Methods:A hospital-based observational studywas conducted on 64 patients admitted to the medical wards, manifesting with symptoms and signs of cirrhosis liver and an abdominal sonology report was taken up for the study. A proforma which includes a detailed history and clinical examination lab investigations ultrasound abdomen and pelvis. Results:Majority of the study participants belonged to the age group of 41 to 50 years (34.4%) and were males (93.4%). In present study majority of patients presented with abdominal distension (84.5%) followed by swelling of lower limbs (81.3%), abdominal pain (45.3%), fever (39.1%), melena(37.5%), hematemesis (25%)In Suthar et al3 study majority of patients presented with ascites(60%), melena (60%), hematemesis (34%), swelling of lower limbs(16%).. 87.5% patients were discharged and 12.5% patients died. Conclusions: There is a need for good health education in patients who are diagnosed as cirrhosis of liver about the complications, screening upper GI endoscopy and further follow up, Immediate control of infections, avoiding constipation by laxatives, cautious use of sedatives and diuretics and proper advice about diet must be part of counselling to cirrhotic patients. [ABSTRACT FROM AUTHOR]

Acute variceal bleeding in cirrhosis represents a critical clinical event that significantly impacts patient prognosis, with mortality rates increasing further after a second episode. This underscores the need for immediate intervention and optimal prophylaxis. The creation of a transjugular intrahepatic portosystemic shunt (TIPS) has been proven to be highly effective for managing esophageal variceal bleeding. However, the use of TIPS for managing cardiofundal gastric varices and ectopic varices remains debated due to their unique vascular anatomy and the limited data available. These varices, although less prevalent than esophageal varices, are complex and heterogeneous vascular shunts between the splanchnic venous system and the systemic veins. Indeed, while endoscopic therapy with tissue adhesives is widely endorsed for achieving hemostasis in active hemorrhage, there is no consensus regarding the optimal approach for secondary prophylaxis. Recent research emphasizes the efficacy of endovascular techniques over endoscopic treatments, such as TIPS and endovascular variceal embolization techniques. This review examines the use of TIPS in managing acute variceal bleeding in patients with cirrhosis, focusing specifically on cardiofundal gastric varices and ectopic varices, discussing optimal patient care based on the latest evidence, aiming to improve outcomes for this challenging subset of patients. [ABSTRACT FROM AUTHOR]

Objective: To assess the relation of grades of esophageal varices with the scoring of Child-Pugh in patients of CLD on Ultrasonography. Study Design: Cross Sectional Study. Setting: Tertiary Care Hospital Sargodha. Period: January 2022 to January 2023. Methods: For this purpose, retrospective study was conducted that included reports from 40 patients of Tertiary Care Hospital Sargodha who underwent endoscopy for esophageal varices and ultrasonography for liver fibrosis after approval from Institutional Ethical Committee. Results: It was found that grades of esophageal varices are related with Child-Pugh classes. Conclusion: Thus, Child-Pugh is an effective way of predicting degree of esophageal varices and in time prophylactic therapy can decrease morbidity and mortality. [ABSTRACT FROM AUTHOR]

Objectives: We aimed to develop and validate a simple scoring system to predict in‐hospital mortality after endoscopic variceal ligation (EVL) for esophageal variceal bleeding. Methods: Data from a 13‐year study involving 46 Japanese institutions were split into development (initial 7 years) and validation (last 6 years) cohorts. The study subjects were patients hospitalized for esophageal variceal bleeding and treated with EVL. Variable selection was performed using least absolute shrinkage and selection operator regression, targeting in‐hospital all‐cause mortality as the outcome. We developed the Hospital Outcome Prediction following Endoscopic Variceal Ligation (HOPE‐EVL) score from β coefficients of multivariate logistic regression and assessed its discrimination and calibration. Results: The study included 980 patients: 536 in the development cohort and 444 in the validation cohort. In‐hospital mortality was 13.6% and 10.1% for the respective cohorts. The scoring system used five variables: systolic blood pressure (<80 mmHg: 2 points), Glasgow Coma Scale (≤12: 1 point), total bilirubin (≥5 mg/dL: 1 point), creatinine (≥1.5 mg/dL: 1 point), and albumin (<2.8 g/dL: 1 point). The risk groups (low: 0–1, middle: 2–3, high: ≥4) in the validation cohort corresponded to observed and predicted mortality probabilities of 2.0% and 2.5%, 19.0% and 22.9%, and 57.6% and 71.9%, respectively. In this cohort, the HOPE‐EVL score demonstrated excellent discrimination ability (area under the curve [AUC] 0.890; 95% confidence interval [CI] 0.850–0.930) compared with the Model for End‐stage Liver Disease score (AUC 0.853; 95% CI 0.794–0.912) and the Child–Pugh score (AUC 0.798; 95% CI 0.727–0.869). Conclusions: The HOPE‐EVL score practically and effectively predicts in‐hospital mortality. This score could facilitate the appropriate allocation of resources and effective communication with patients and their families. [ABSTRACT FROM AUTHOR]

Esophageal varices (EV) in liver cirrhosis carry high mortality risks. Traditional endoscopy, which is costly and subjective, prompts a shift towards machine learning (ML). This review critically evaluates ML applications in predicting bleeding risks and grading EV in patients with liver cirrhosis. Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta‐Analyses) guidelines, we conducted a systematic review of studies using ML to predict the risk of variceal bleeding and/or grade EV in liver disease patients. Data extraction and bias assessment followed the CHARMS (CHecklist for critical Appraisal and data extraction for systematic Reviews of prediction Modeling Studies) checklist and PROBAST (Prediction model Risk Of Bias Assessment Tool) tool, respectively. Due to the heterogeneity of the study, a meta‐analysis was not feasible; instead, descriptive statistics summarized the findings. Twelve studies were included, highlighting the use of various ML models such as extreme gradient boosting, artificial neural networks, and convolutional neural networks. These studies demonstrated high predictive accuracy, with some models achieving area under the curve values above 99%. However, significant heterogeneity was noted in input variables, methodologies, and outcome measures. Moreover, a substantial portion of the studies exhibited unclear or high risk of bias, mainly due to insufficient participant numbers, unclear handling of missing data, and a lack of detailed reporting on endoscopic procedures. ML models show significant promise in predicting the risk of variceal bleeding and grading EV in patients with cirrhosis, potentially reducing the need for invasive procedures. Nonetheless, the current literature reveals considerable heterogeneity and methodological limitations, including high or unclear risks of bias. Future research should focus on larger, prospective trials and the standardization of ML assessment criteria to confirm these models' practical utility in clinical settings. [ABSTRACT FROM AUTHOR]

Background: The prognosis comparison between endoscopic therapy + partial splenic embolization (PSE) and Hassab's operation is unclear in the treatment of esophageal variceal bleeding in patients with liver cirrhosis. This study aimed to compare the outcome of endoscopic therapy + PSE (EP) with a combination of splenectomy + pericardial devascularization procedure, known as Hassab's operation (SH) for esophageal variceal bleeding in patients with liver cirrhosis with hypersplenism. Methods: We enrolled 328 patients, including 125 and 203 patients who underwent EP and SH, respectively. Each group consisted of 110 patients after propensity score matching (PSM). Subsequently, we recorded and analyzed bleeding episodes and mortality in 6 months and 1, 2, and 5 years after therapies. Results: The median follow-up time in the EP and SH groups was 53 and 64 months, respectively. Bleeding incidence 6 months after therapies in the EP group was lower than that in the SH group (1.8% vs. 10.0%, P = 0.010). Additionally, complications in the perioperative period were not significantly different (0% vs. 3.6%, P = 0.008). However, the bleeding rate between the two groups was not significantly different at 1, 2, and 5 years after therapies (7.3% vs. 12.7%, P = 0.157; 10.9% vs. 16.4%, P = 0.205; 30.6% vs. 31.8%, P = 0.801), as well as mortality rate (4.5% vs 7.3%, P = 0.571). Conclusion: Compared with SH therapy, the bleeding rate 6 months after EP therapy was lower, but the long-term bleeding rate was similar. [ABSTRACT FROM AUTHOR]

Background: Variceal hemorrhage treatment includes endoscopy within 12 hours of admission and octreotide therapy for 2-5 days post-endoscopy. Duration of pre-endoscopy octreotide can be prolonged when intervention is delayed. Objective: This study aimed to evaluate the impact of extended pre-endoscopy octreotide on rebleeding after endoscopy when comparing short vs long durations of post-endoscopy octreotide. Methods: This was a single center, retrospective cohort evaluating adult cirrhotic patients with esophageal variceal hemorrhage admitted between July 1, 2017 and June 30, 2020. Study groups included patients receiving octreotide ≥12 hours prior to endoscopy followed by ≤ 48 (short course) or >48 hours (standard course) after endoscopy. The primary outcome was post-endoscopy rebleeding, defined as hemoglobin decrease of ≥2 g/dL from baseline or the requirement of ≥1 unit of packed red blood cells. Results: Of the 169 patients included, 88 patients received short course octreotide after endoscopy, and 81 patients received standard course octreotide after endoscopy. Twenty-nine (33%) patients in the short course group and 43 (53.1%) in the standard course group experienced the primary endpoint (OR 2.3, 95% CI 1.24 - 4.29; P =.008). Conclusion: Extended pre-endoscopy octreotide may be beneficial in preventing rebleeding when intervention is delayed. Further studies are needed to determine the necessary octreotide duration in delayed endoscopy and varying bleeding risk. [ABSTRACT FROM AUTHOR]

Non-alcoholic fatty liver disease (NAFLD) is the most common liver disease. We aimed to investigate the potential similarities and differences regarding the disease among Arabs and Jews. Retrospective study included all patients older than 18 years with NAFLD diagnosis according to ICD-10 codes. Data regarding demographics, comorbidities, and outcomes were retrieved using the MdClone platform from "Clalit" in Israel. Data concerning 34,090 Arab patients and 173,500 Jewish patients with NAFLD were included. Arab patients were significantly younger at diagnosis (35.0 ± 13 years vs. 43.6 ± 15 years, p < 0.001) and had higher rates of obesity and diabetes mellitus (69.5% vs. 56.5% and 27.0% vs. 22.7%, p < 0.001, respectively). Arab patients had higher rates of cirrhosis and portal hypertension-related complications (2.5% vs. 2.0%, p < 0.001), esophageal varices (0.9% vs. 0.5%, p < 0.001), spontaneous bacterial peritonitis (0.3% vs. 0.1%, p < 0.001), and hepatorenal syndrome (0.3% vs. 0.1%, p < 0.001). There was no significant difference in the prevalence of hepatocellular carcinoma between study groups (0.4% vs. 0.5%, p = 0.156). Liver transplantation was performed in 0.2% of Arab NAFLD patients compared to 0.07% of Jewish NAFLD patients (p < 0.001). Lower rates of all-cause mortality were found among the Arab NAFLD patients versus Jewish NAFLD patients (7.7% versus 11.5%, p < 0.001). According to the Cox regression model, Arab ethnicity is a risk factor for death with OR of 1.36. Significant differences regarding comorbidities, complications, liver transplantations rates, and all-cause mortality were found among NAFLD patients of different ethnicities, hence specific population need specific consideration in prevention, early diagnosis and follow up. [ABSTRACT FROM AUTHOR]

Background: We report a rare case highlighting the progression of liver disease in a male patient with idiopathic childhood-onset growth hormone (GH) deficiency. Case presentation: The patient was diagnosed with hypopituitarism at six years old and was treated with thyroxine therapy and GH for his short stature, with testosterone added at the age of 15. GH therapy was discontinued when the patient was 18 years old, but thyroid and testosterone treatments continued. The patient had been taking medication for hyperlipidemia until the age of 30 and was noted to have impaired glucose tolerance at the age of 40, but HbA1c levels remained normal. At the age of 47, esophageal varices were incidentally discovered via endoscopy, revealing liver cirrhosis. Laboratory tests showed liver dysfunction and abnormal lipid levels, and hepatitis viral markers were absent. The patient had no history of drinking alcohol or smoking, and no family history of diabetes. Results: Ultimately, this case demonstrates that metabolic dysfunction-associated steatotic liver disease (MASLD/metabolic dysfunction-associated steatohepatitis (MASH)) is under-recognized in GH deficiency cases and can progress to liver cirrhosis. Conclusions: Therefore, careful evaluation of MASLD/MASH in childhood-onset GH deficiency is necessary, and GH replacement therapy should continue into adulthood, if possible. [ABSTRACT FROM AUTHOR]

Objectives: To assess the role of 4D flow MRI in the assessment of gastro-oesophageal varices and in the prediction of high-risk varices in patients with chronic liver disease. Methods: Thirty-eight patients diagnosed with either oesophageal or gastric varices were included in this single-centre prospective study. 4D flow MRI was used to calculate peak flow, average flow and peak velocity at the portal vein confluence (PV1) and hilum (PV2), splenic vein hilum (SV1) and confluence (SV2), and superior mesenteric vein (SMV). PV and SV fractional flow changes were also measured. Results: ROC analysis revealed that both PV2 average flow and PV fractional average flow change had 100% sensitivity to predict high-risk patients with the PV fractional peak flow change having the widest area under the curve (AUC) and the highest specificity (92.3%). SV1 average flow, SV2 average flow, SV2 peak flow, and SV2 peak velocity increased significantly in patients with oesophageal compared to gastric varices included (p = 0.022, < 0.001, < 0.001 and 0.001, respectively). Conclusion: Based on certain porto-mesenteric blood flow, velocity, and fractional flow change parameters, 4D flow MRI showed excellent performance in identifying high-risk patients and giving an idea about the grade and location of varices. Critical relevance statement: Variceal bleeding is a major consequence of unidentified risky upper GI varices. Thus, by identifying and locating high-risk varices early, either oesophageal or gastric, using a non-invasive method like MRI, adverse events might be avoided. Key Points: 4D flow MRI can be used as a potential alternative for endoscopy to predict patients with high-risk varices. Based on portal vein fractional flow change, splenic flow and velocity, 4D MRI can predict and locate high-risk varices. Earlier identification of high-risk varices can allow for interventions to prevent adverse events. [ABSTRACT FROM AUTHOR]

Summary: Background: Oesophageal disorders and chronic liver disease are common worldwide and significantly impact quality of life. The intricate link between these conditions, including how oesophageal disorders like GERD, Barrett's oesophagus and oesophageal cancer affect and are affected by chronic liver disease, remains poorly understood. Aims: To review the relationship between oesophageal disorders and chronic liver disease, evaluating epidemiology, pathophysiology and therapeutic factors. Methods: We reviewed the literature on the relationship between oesophageal disorders and chronic liver disease, including cirrhosis, using the PubMed database Results: Oesophageal disorders such as gastroesophageal reflux disease, Barrett's oesophagus, oesophageal cancer, oesophageal motor disorders and oesophageal candidiasis are prevalent among individuals with cirrhosis, exacerbating the burden of liver disease. These diseases have a multifaceted symptomatology and pathogenic basis, posing a significant challenge in cirrhotic patients that necessitates careful diagnosis and management. Additionally, therapies frequently used for these diseases, such as proton pump inhibitors, require careful consideration in cirrhotic patients due to potential adverse effects and altered pharmacokinetics. Managing oesophageal disorders in cirrhotic patients requires a cautious approach due to possible interactions with medications and the risk of adverse effects. Furthermore, symptoms associated with these conditions are often exacerbated by common interventions in patients with cirrhosis, such as band ligation for oesophageal varices. Conclusions: Oesophageal disorders are common in cirrhosis and increase the disease burden. These conditions require careful management due to complex symptoms and treatment risks. Proton pump inhibitors and other therapies must be used cautiously, as cirrhosis interventions can worsen symptoms. [ABSTRACT FROM AUTHOR]

Background: Esophageal diseases (ED) are a kind of common diseases of upper digestive tract. Previous studies have proved that metabolic disorders are closely related to the occurrence and development of ED. However, there is a lack of evidence for causal relationships between metabolites and ED, as well as between metabolite ratios representing enzyme activities and ED. Herein, we explored the causality of genetically determined metabolites (GDMs) on ED through Mendelian Randomization (MR) study. Methods: Two-sample Mendelian randomization analysis was used to assess the causal effects of genetically determined metabolites and metabolite ratios on ED. A genome-wide association analysis (GWAS) encompassing 850 individual metabolites along with 309 metabolite ratios served as the exposures. Meanwhile, the outcomes were defined by 10 types of ED phenotypes, including Congenital Malformations of Esophagus (CME), Esophageal Varices (EV), Esophageal Obstructions (EO), Esophageal Ulcers (EU), Esophageal Perforations (EP), Gastroesophageal Reflux Disease (GERD), Esophagitis, Barrett's Esophagus (BE), Benign Esophageal Tumors (BETs), and Malignant Esophageal Neoplasms (MENs). The standard inverse variance weighted (IVW) method was applied to estimate the causal relationship between exposure and outcome. Sensitivity analyses were carried out using multiple methods, including MR-Egger, Weighted Median, MR-PRESSO, Cochran's Q test, and leave-one-out analysis. P < 0.05 was conventionally considered statistically significant. After applying the Bonferroni correction for multiple testing, a threshold of P < 4.3E-05 (0.05/1159) was regarded as indicative of a statistically significant causal relationship. Furthermore, metabolic pathway analysis was performed using the web-based MetaboAnalyst 6.0 software. Results: The findings revealed that initially, a total of 869 candidate causal association pairs ( P ivw < 0.05) were identified, involving 442 metabolites, 145 metabolite ratios and 10 types of ED. However, upon applying the Bonferroni correction for multiple testing, only 36 pairs remained significant, involving 28 metabolites (predominantly lipids and amino acids), 5 metabolite ratios and 6 types of ED. Sensitivity analyses and reverse MR were performed for these 36 causal association pairs, where the results showed that the pair of EV and 1-(1-enyl-palmitoyl)-2-linoleoyl-GPE (p-16:0/18:2) did not withstand the sensitivity tests, and Hexadecenedioate (C16:1-DC) was found to have a reverse causality with GERD. The final 34 robust causal pairs included 26 metabolites, 5 metabolite ratios and 5 types of ED. The involved 26 metabolites predominantly consisted of methylated nucleotides, glycine derivatives, sex hormones, phospholipids, bile acids, fatty acid dicarboxylic acid derivatives, and N-acetylated amino acids. Furthermore, through metabolic pathway analysis, we uncovered 8 significant pathways that played pivotal roles in five types of ED conditions. Conclusions: This study integrated genomics with metabolomics to assess causal relationships between ED and both metabolites and metabolite ratios, uncovering several key metabolic features in ED pathogenesis. These findings have potential as novel biomarkers for ED and provide insights into the disease's etiology and progression. However, further clinical and experimental validations are necessary [ABSTRACT FROM AUTHOR]

Background: In patients with cirrhosis, esophageal variceal hemorrhage (EVH) is a devastating consequence of portal hypertension (PH). Upper endoscopy is considered the gold standard for the detection and diagnosis of esophageal varices (EVs), despite being invasive and costly. This study was aimed at identifying and evaluating the diagnostic accuracy of noninvasive tools in predicting EVs in patients with compensated cirrhosis. Methods: This cross‐sectional study included 50 patients with compensated cirrhosis at the Tygerberg Hospital Gastroenterology Clinic in Cape Town between November 2022 and May 2023. We collected clinical, anthropometric, and laboratory data from patients' physical and electronic charts. All patients underwent an abdominal ultrasound, vibration‐controlled transient elastography (VCTE) to assess liver and splenic stiffness, and upper endoscopy. In this comparative study, we evaluated the diagnostic accuracy of different noninvasive tools in detecting EVs in patients with compensated cirrhosis. Results: Of the 50 patients included in the study, 30 (60%) were female and 20 (40%) were male. The patients' age ranged from 18 to 83, with a mean age of 46.6 years. Cirrhosis was mainly due to alcohol use (n = 11, 22%), hepatitis B virus (HBV) infection (n = 11, 22%), and autoimmune hepatitis (n = 10, 20%). The patients included in the study were divided into two subgroups: with (n = 34, 68%) or without (n = 16, 32%) EVs. Statistically significant differences were detected between groups in platelet count (PC), liver stiffness measurement (LSM), spleen stiffness measurement (SSM), portal vein diameter (PVD), bipolar spleen diameter (SBD), aspartate aminotransferase‐to‐platelet ratio index (APRI), fibrosis‐4 index (FIB‐4), platelet/bipolar spleen diameter ratio (PSR), liver stiffness‐spleen size‐platelet ratio (LSPS), liver stiffness‐spleen stiffness‐platelet ratio score (LS3PS), and spleen stiffness‐spleen size‐platelet ratio score (SSPS) (p < 0.001). The highest diagnostic precision was observed with SSM (96%), SSPS (96%), LS3PS (94%), LSPS (94%), PSR (94%), and PC (92%). SBD (88%), LSM (86%), APRI (82%), and FIB‐4 (82%) had the lowest diagnostic accuracy. Conclusion: SSM and SSPS have the highest diagnostic accuracy for predicting the presence of EVs in patients with compensated cirrhosis. LSPS, LS3PS, and PSR come second at 94%. We recommend SSM and SSPS in institutions with transient elastography equipped with the software necessary to measure splenic stiffness. We introduce and propose LS3PS as a novel composite score for predicting the presence of EVs in patients with compensated cirrhosis. Large‐sample‐size studies are needed to validate these prediction scores and to allow direct comparison with Baveno VII. These prediction tools can help clinicians avoid unnecessary endoscopic procedures in patients with compensated cirrhosis, especially in developing countries with limited resources such as South Africa. [ABSTRACT FROM AUTHOR]

Background: Esophageal varices, dilated submucosal veins in the lower esophagus, are commonly associated with portal hypertension, particularly due to liver cirrhosis. The high morbidity and mortality linked to variceal hemorrhage underscore the need for accurate diagnosis and effective management. The traditional method of assessing esophageal varices is esophagogastroduodenoscopy (EGD), which, despite its diagnostic and therapeutic capabilities, presents limitations such as interobserver variability and invasiveness. This review aims to explore the role of artificial intelligence (AI) in enhancing the management of esophageal varices, focusing on its applications in diagnosis, risk stratification, and treatment optimization. Methods: This systematic review focuses on the capabilities of AI algorithms to analyze clinical scores, laboratory data, endoscopic images, and imaging modalities like CT scans. Results: AI-based systems, particularly machine learning (ML) and deep learning (DL) algorithms, have demonstrated the ability to improve risk stratification and diagnosis of esophageal varices, analyzing vast amounts of data, identifying patterns, and providing individualized recommendations. However, despite these advancements, clinical scores based on laboratory data still show low specificity for esophageal varices, often requiring confirmatory endoscopic or imaging studies. Conclusions: AI integration in managing esophageal varices offers significant potential for advancing diagnosis, risk assessment, and treatment strategies. While promising, AI systems should complement rather than replace traditional methods, ensuring comprehensive patient evaluation. Further research is needed to refine these technologies and validate their efficacy in clinical practice. [ABSTRACT FROM AUTHOR]

Felty syndrome is a rare and serious complication of Rheumatoid Arthritis (RA), characterised by a triad of RA, splenomegaly (enlarged spleen), and neutropenia (low neutrophil count). RA, a systemic autoimmune inflammatory disease marked by synovitis, commonly occurs in the fifth or sixth decade of life and often affects patients with a history of RA exceeding ten years. It is more prevalent in the Caucasian population due to the underexpression of the Human Leukocyte Antigen (HLA)-DR4 gene in African Americans. Felty syndrome requires the presence of neutropenia, defined as an Absolute Neutrophil Count (ANC) below 2000 cells/mm³, alongside splenomegaly and long-standing RA. Hereby, the authors present a case report of a 44-year-old female with a three-year history of RA, who presented with ascites for nine months and was found to have portal hypertension. Her diagnosis of Felty syndrome was confirmed based on the triad of RA, neutropenia, and splenomegaly, highlighting the importance of early recognition and management to prevent severe complications such as infections and systemic issues like portal hypertension. [ABSTRACT FROM AUTHOR]

This document provides a summary of a study on the long-term surveillance of gastric varices (GV) in patients with non-cirrhotic portal hypertension (NCPH). The study found that repeat secondary prophylactic interventions for GV rarely occur beyond four years, and rebleeding can still occur despite endoscopic ultrasound (EUS) surveillance and treatment. However, late rebleeding may have a good prognosis. The study suggests that larger prospective cohorts would be valuable to confirm these findings. The document also includes supplementary materials related to the article and information about conflicts of interest and funding. [Extracted from the article]

Background and Aims: Impact of type 2 diabetes mellitus (T2DM) in patients with end-stage liver disease (ESLD) awaiting liver transplantation (LT) remains poorly defined. The objective of the present study is to evaluate the relationship between T2DM and clinical outcomes among patients with LT waitlist registrants. We hypothesize that the presence of T2DM will be associated with worse clinical outcomes. Methods: 593 patients adult (age 18 years or older) who were registered for LT between 1/2010 and 1/2017 were included in this retrospective analysis. The impact of T2DM on liver-associated clinical events (LACE), survival, hospitalizations, need for renal replacement therapy, and likelihood of receiving LT were evaluated over a 12-month period. LACE was defined as variceal hemorrhage, hepatic encephalopathy, and ascites. Kaplan–Meier and Cox regression analysis were used to determine the association between T2DM and clinical outcomes. Results: The baseline prevalence of T2DM was 32% (n = 191) and patients with T2DM were more likely to have esophageal varices (61% vs. 47%, p = 0.002) and history of variceal hemorrhage (23% vs. 16%, p = 0.03). The presence of T2DM was associated with increased risk of incident ascites (HR 1.91, 95% CI 1.11, 3.28, p = 0.019). Patients with T2DM were more likely to require hospitalizations (56% vs. 49%, p = 0.06), hospitalized with portal hypertension-related complications (22% vs. 14%; p = 0.026), and require renal replacement therapy during their hospitalization. Patients with T2DM were less likely to receive a LT (37% vs. 45%; p = 0.03). Regarding MELD labs, patients with T2DM had significantly lower bilirubin at each follow-up; however, no differences in INR and creatinine were noted. Conclusion: Patients with T2DM are at increased risk of clinical outcomes. This risk is not captured in MELD score, which may potentially negatively affect their likelihood of receiving LT. [ABSTRACT FROM AUTHOR]

Objectives: Upper gastrointestinal bleeding (GIB) in patients has been well-characterized in liver cirrhosis but studies on lower GIB are limited. The clinical characteristics, management and outcomes in patients with and without liver cirrhosis was compared to determine the overall features of GIB in patients with liver cirrhosis compared with non-cirrhotics. Methods: A retrospective study on cirrhotics hospitalized for GIB 2010–2021, matched with control group of non-cirrhotics (1:4) for upper vs. lower GIB. Patients with overt bleeding leading to hospitalization were included. Results: Overall, 396 patients had cirrhosis, 267 (67%) men, median age 62, alcoholic etiology 177/396 (45%), median MELD 12 (range 6–32). Overall 102 cirrhotics had GIB, matched with 391 non-cirrhotics. Overall 87 (85%) cirrhotic patients had upper and 15% lower GIB. Compared to non-cirrhotics, the cause of GIB was more commonly acute variceal bleeding (AVB) (42% vs. 1%), hemorrhoids 40% vs. 6% (p = 0.002), less commonly gastric ulcer 13% vs. 31% (p < 0.001), duodenal ulcer 9% vs. 29% (p < 0.001), 5% of cirrhotics used NSAIDs vs. 26% of controls (p < 0.001). Rebleeding occurred in 14% of cirrhotics vs. 3% in controls (p < 0.001). Only one cirrhotic patient (1%) died from GIB vs. 0.8% of controls within 45 days. Overall mortality 45 days after hospitalization was 10% in cirrhotics vs. 5% in controls (p < 0.001) Conclusions: Bleeding from gastric and duodenal ulcers were less common in cirrhotics than in controls. Bleeding from hemorrhoids was more common in cirrhotics. Mortality due to GIB was low in both groups but overall mortality was significantly higher in cirrhotics. [ABSTRACT FROM AUTHOR]

Introduction and objectives: Laparoscopic splenectomy and esophagogastric devascularization (LSED) are minimally invasive, effective, and safe in treating esophageal-fundic variceal bleeding with portal hypertension (PHT). The study aimed to assess the learning curve of LSED by cumulative summation (CUSUM) analysis. The 10-year follow-up data for LSED and open surgery were also examined. Patients and methods: Five hundred and ninety-four patients were retrospectively analyzed. Operation time, intraoperative blood loss, open operation conversion, and postoperative complications were selected as the evaluation indicators of surgical ability. The learning curve of LESD was assessed by the CUSUM approach. Patient features, perioperative indices, and 10-year follow-up data were examined. Results: Totally 236 patients underwent open surgery, and 358 underwent LSED. Patient characteristics were similar between groups. The LSED patients experienced less intraoperative blood loss, fewer complications, and faster recovery compared to the open surgery cohort. The learning curve of LESD was maximal for a case number of 50. Preoperative general characteristics were comparable for both stages. But the skilled stage had decreased operation time, reduced blood loss, less postoperative complications, and better recovery compared to the learning stage. The LSED group had higher recurrent hemorrhage-free survival rate and increased overall survival in comparison with cases administered open surgery in the 10-year follow-up. Free-liver cancer rates were similar between two groups. Conclusions: About 50 cases are needed to master the LSED procedure. Compared to open surgery, LSED is a safer, feasible, and safe procedure for PHT patients, correlating with decreased rebleeding rate and better overall survival. [ABSTRACT FROM AUTHOR]

Purpose: Liver stiffness measurement (LSM) by transient elastography has been shown to underperform in high-risk varices (HRVs) prediction in obese non-alcoholic fatty liver disease (NAFLD) compensated cirrhosis (CC). LSM by magnetic resonance elastography (MRE) and acoustic force radiation impulse (ARFI) has been shown to be useful in prediction of oesophageal varices (EVs), but has limited evidence in obese NAFLD-CC. Methods: Obese patients with NAFLD-CC who underwent MRE and ARFI for LSM and endoscopy for screening of varices were enrolled. Performance of MRE and ARFI for predicting EVs or HRVs was evaluated using area under receiver operating characteristics (AUROC) curves and regression analyses were performed for predictor variables. Results: One hundred eight patients [mean age 54.7 ± 9.6 years, median BMI, 28.5 (26.4–30.0) kg/m2. 72.2% diabetics, 45.4% hypertensive] were enrolled. Fifty-two (48.1%) had no varices, while 29 (26.8%) and 27 (25%) had low-risk varices (LRVs) and HRVs, respectively. MRE-LSM was higher in patients with LRVs (p = 0.01) or HRVs (p = 0.001) against those without varices. ARFI-LSM did not differ significantly between those without and with LRVs or HRVs (p > 0.05 for all). There was a low correlation between ARFI-LSM and MRE-LSM in the overall cohort (r = 0.19). Only platelet count (PC) [0.98 (0.97–0.99)] and MRE-LSM [1.8 (1.26–2.79)] were predictors of HRVs. At a cut-off of 4.75, MRE showed a sensitivity of 96.3%. Model combining MRE-LSM with PC had a diagnostic AUROC of 0.77 and 0.76 for EVs and HRVs. Conclusion: In obese NAFLD-CC, MRE-LSM is significantly higher in patients with varices. MRE combined with PC predicts EVs and HRVs with better accuracy than ARFI. [ABSTRACT FROM AUTHOR]

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To clarify the risk factors for the aggravation of esophagogastric varices (EGVs) after hepatitis C virus (HCV) eradication with direct-acting antiviral (DAA) therapy, we enrolled 167 consecutive patients with HCV-related compensated cirrhosis who achieved a sustained virological response (SVR) after DAA therapy. During a median of 69 months, EGVs were aggravated in 42 (25%) patients despite SVR. The cumulative 1-, 3-, 5-, and 10-year aggravated EGV rates were 7%, 23%, 25%, and 27%, respectively. Multivariate analysis identified a platelet count < 11.0 × 104/μL, LSM ≥ 18.0 kPa, total bile acid ≥ 33.0 μmol/L, and a diameter of left gastric vein (LGV) ≥ 5.0 mm at HCV eradication as independent risk factors for EGV aggravation post-SVR. In groups that met all of these risks, the cumulative EGV aggravation rates at 1, 3, and 5 years were 27%, 87%, and 91%, respectively. However, none of the patients who had only one or none of the risk factors experienced EGV aggravation. Platelet count, LSM, total bile acid, and diameter of LGV at HCV eradication were associated with aggravated EGV post-SVR. EGVs tend to worsen as two or more of these risk factors increase. [ABSTRACT FROM AUTHOR]

In Europe, transjugular intrahepatic portosystemic shunt (TIPS) is considered the primary treatment for gastric varix (GV) bleeding to reduce portal hypertension. However, in Asian countries, balloon-occluded retrograde transvenous obliteration (BRTO) and its variants plug/coil assisted transvenous retrograde obliteration (PARTO/CARTO) are the preferred approaches. The purpose of this study is to report a European single-center experience in the use of PARTO/CARTO techniques for the treatment of GVs in patients with portal hypertension, focusing on the effectiveness and safety of the procedure. All the procedures involving the PARTO/CARTO techniques performed from 2019 to 2023 were retrospectively evaluated. Technical success was defined as the complete obliteration of both the GVs and the gastro-renal (GR) shunt on review of the Computed Tomography (CT) scan performed 3 days after the procedure. The obliteration rate was also evaluated through performing CT scans 1 and 12 months after the procedure, and through endoscopic follow-up at 3 and 6 months. Additionally, major and minor complications were reported. The study involved seven patients, with a technical success of 100%. During follow-up, there were no episodes of variceal rebleeding or upper gastrointestinal bleeding. Two patients developed ascites, which resolved with medical therapy. One patient exhibited focal portal thrombosis, which was successfully treated with heparin. PARTO/CARTO techniques demonstrated high technical and clinical success rates, offering advantages over traditional BRTO. The use of coils and plugs simplifies the procedure, eliminates sclerosing agents, and prevents complications associated with balloon guiding catheters. [ABSTRACT FROM AUTHOR]

Abstract Background This study aimed to compare the diagnostic efficacy of Two-dimensional shear wave elastography (2D-SWE) with that of transient elastography (TE) in predicting the risk of esophagogastric varices and histological staging in patients with primary biliary cholangitis (PBC). Methods This single-center prospective study enrolled the patients with PBC diagnosed by liver biopsy following 2D-SWE and TE. Receiver operating characteristic (ROC) curves were constructed for SWE-liver stiffness measurement (LSM) and TE-LSM to assess their diagnostic efficacy for histological staging ≥ stage 2, ≥ stage 3, and = stage 4. The diagnostic efficacy and accuracy of SWE-LSM were compared with those of the Baveno VI criteria for detecting esophagogastric varices. Additionally, the impact of different laboratory parameters on SWE-LSM was analyzed. Results We evaluated 77 patients (median age, 52 years (range: 16 − 75 years), 66 females). ROC curves constructed using TE-LSM and SWE-LSM demonstrated similar diagnostic efficacy for histological staging ≥ stage 2 (area under the curve [AUC]: 0.824 vs. 0.823 for TE-LSM and SWE-LSM, respectively, p = 0.9764), ≥ stage 3 (AUC: 0.918 vs. 0.907 for TE-LSM and SWE-LSM, respectively, p = 0.6443), and = stage 4 (AUC: 0.907 vs. 0.902 for TE-LSM and SWE-LSM, respectively, p = 0.8763). Additionally, while there was no significant difference in the diagnostic efficacy between the two methods for detecting esophagogastric varices (Z = 1.516, p = 0.1296), 2D-SWE had a slightly higher diagnostic accuracy than TE (61.8% vs. 76.4%). Transaminases and bilirubin levels had little influence on SWE-LSM. Conclusion 2D-SWE exhibited comparable performance to TE in predicting the risk of esophagogastric varices and histological staging.

Abstract Objective The aim of our study was to evaluate the indocyanine green (ICG) retention test as a noninvasive marker of esophageal varices(EV). Methods The clinical data of patients diagnosed with compensated liver cirrhosis in Tianjin Second People’s Hospital between January 2018 and January 2021 were analysed with SPSS 23.0. Result A total of 144 patients (88 M/56 F, 51.7 ± 11.06 years) were enrolled. The ICG retention at 15 min(ICG-r15), PVD, TBIL, Cholinesterase(CHE), AST to ALT ratio(ARR), APRI, splenic area, Lok index, Park index and liver stiffness measurement in the absent or small EV group were lower than those in the medium or large EV group, while the ICG disappareance rate(ICG-K), Effective hepatic blood flow(EHBF), ALB, PLT, and Platelet to Spleen Diameter Ratio(PSDR) were higher, and the differences were significant (P

Introduction: Esophageal varices (EVs) carry a significant risk of rupture and subsequent life-threatening bleeding. While previous research has investigated the effectiveness of the platelet count to spleen diameter ratio (PC/SD) as a non-invasive predictor of EVs in various populations, this study specifically focuses on the Iranian population to assess the applicability and effectiveness of this parameter in this region. Materials and Methods: Upper gastrointestinal endoscopy was performed on 147 cirrhotic patients to screen for EVs. Biochemical tests and ultrasonography were done to measure spleen diameter (SD) and calculate the PC/SD ratio. ROC analysis was done to determine the predictive performance of the parameters. Results: Among the patients, 73% had EVs. The analysis showed the following: platelet count (PC) had an AUC of 0.695 with 78.7% sensitivity and 56.4% specificity; SD had an AUC of 0.750 with 49.1% sensitivity and 89.7% specificity; and the PC/SD ratio had an AUC of 0.734 with 60.2% sensitivity and 79.5% specificity. The PC/SD ratio exhibited a high positive predictive value of 93% but a low negative predictive value of 41.9%. Optimal cutoff values were determined as follows: PC≤ 100,000, SD< 163, and PC/SD ratio≤ 523. Conclusion: By identifying high-risk patients who may benefit from targeted endoscopic screening, this non-invasive method could contribute to improving overall patient care and reducing the need for invasive procedures. However, due to suboptimal performance results, it is crucial to use this approach with caution, as endoscopic screening remains the standard practice for the diagnosis and management of esophageal varices.

Background & aim: SGLT2 inhibitors (SGLT2i) improve hepatic steatosis in patients with type 2 diabetes mellitus (T2DM) and MASLD. We aimed to investigate the impact of SGLT2i on the incidence of liver-related events and extrahepatic cancer compared to DPP4 inhibitors (DPP4i) in patients with T2DM and suspected MASLD using a medical claims database in Japan. Methods: We conducted a retrospective study using a Japanese medical claims database. Among patients with T2DM who were prescribed SGLT2i or DPP4i (n = 1,628,656), patients with suspected MASLD were classified into SGLT2i (n = 4204) and DPP4i (n = 4204) groups. Effects of SGLT2i on the following outcomes were compared to DPP4i: (1) changes in HbA1c and ALT levels after 6 months, (2) changes in hepatic fibrosis index, and (3) the incidence of liver-related events/extrahepatic cancer over 12 months. Results: After 6 months, DPP4i significantly decreased HbA1c levels compared to SGLT2i. In contrast, SGLT2i significantly decreased ALT levels compared to DPP4i. SGLT2i significantly decreased FIB-4 index compared to DPP4i over 12 months. Although no significant difference was observed in the incidence of overall liver-related events between the two groups, SGLT2i significantly reduced the incidence of esophageal varices (HR 0.12, 95%CI 0.01–0.95, P = 0.044). Moreover, SGLT2i significantly suppressed the incidence of extrahepatic cancer (HR 0.50, 95%CI 0.30–0.84, P = 0.009) compared to DPP4i. Conclusion: SGLT2i was more beneficial than DPP4i in improving the hepatic inflammation and fibrosis indices. Moreover, SGLT2i suppressed the incidence of esophageal varices and extrahepatic cancer compared to DPP4i. SGLT2i may suppress life-threatening events in patients with T2DM and suspected MASLD. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the diagnostic performance of radiomics models derived from multi-phase spleen CT for high-risk esophageal varices (HREV) in cirrhotic patients. Methods: We retrospectively selected cirrhotic patients with esophageal varices from two hospitals from September 2019 to September 2023. Patients underwent non-contrast and contrast-enhanced CT scans and were categorized into HREV and non-HREV groups based on endoscopic evaluations. Radiomics features were extracted from spleen CT images in non-contrast, arterial, and portal venous phases, with feature selection via lasso regression and Pearson's correlation. Ten machine learning models were developed to diagnose HREV, evaluated by area under the curve (AUC). The AUC values of the three groups of models were statistically compared by the Kruskal–Wallis H test and Bonferroni-corrected Mann–Whitney U test. A p-value less than 0.05 was considered statistically significant. Results: Among 233 patients, 11, 6, and 11 features were selected from non-contrast, arterial, and portal venous phases, respectively. Significant differences in AUC values were observed across phases (p < 0.05), and the arterial phase models showed the highest AUC values. The best model in arterial phase was the logical regression model, whose AUC value was 0.85, sensitivity was 83.3%, specificity was 80% and F1 score was 0.81. Conclusion: Radiomics models based on spleen CT, especially the arterial phase models, demonstrate high diagnostic accuracy for HREV, offering the potential for early detection and intervention. [ABSTRACT FROM AUTHOR]

Bleeding-related adverse events may occur due to anti-vascular endothelial growth factors. Here, we report two cases of variceal rupture during atezolizumab plus bevacizumab (ATZ/BV) treatment for unresectable hepatocellular carcinoma (u-HCC). Case 1 involved a man in his 60 s with alcoholic liver cirrhosis (LC) and u-HCC. Seventy-four days after ATZ/BV administration, the patient was admitted for hematemesis. Upper esophagogastroduodenoscopy (EGD) revealed worsening of the esophageal varices (EVs) to F2 grade with active bleeding. Endoscopic variceal ligation successfully achieved hemostasis. Case 2 involved a man in his 70 s with alcoholic LC and u-HCC. The patient was admitted with hematemesis 114 days after ATZ/BV administration. During EGD, the EVs deteriorated to F3 grade, although hemostasis had already been achieved. The evaluation was discontinued during the observation stage because of the worsening hepatic reserve. Neither patient had EVs warranting prophylactic treatment before ATZ/BV administration, showed a partial tumor response, or had portal vein tumor thrombus. Both patients demonstrated increased total diameters of the collateral veins and splenic volume compared to those before treatment. These findings suggest that ATZ/BV treatment may increase portal pressure. In conclusion, the administration of ATZ/BV to patients with LC and u-HCC necessitates careful management of EVs aggravation and rupture. [ABSTRACT FROM AUTHOR]

Abstract Background Portal hypertensive enteropathy (PHE) is a small-bowel lesion observed in patients with portal hypertension. The clinical significance of endoscopic findings in PHE remains unclear. We aimed to clarify the clinical significance and predictive factors of capsule endoscopic findings in patients with PHE based on long-term outcomes. Methods This retrospective study enrolled 55 patients with PHE (33 males and 22 females; median age, 64 years; range, 23–87) followed for > 3 years using capsule endoscopy (CE) between February 2009 and May 2023. We evaluated the clinical factors affecting PHE exacerbations and the effects of PHE exacerbations on gastrointestinal bleeding by comparing exacerbated and unchanged PHE groups. Results Overall, 3 (5%) patients showed improvement, 33 (60%) remained unchanged, and 19 (35%) showed exacerbation on follow-up CE. In the exacerbated group, the rates of worsened fibrosis-4 index, exacerbated esophageal varices, and exacerbated portal hypertensive gastropathy were significantly higher than those in the unchanged group (21%, 32%, and 42% vs. 3%, 6%, and 12%, respectively; P

Abstract Background Portal hypertension is a common diagnosis in Sub-Saharan African countries, with the majority of patients presenting late. This study aimed to understand Clinical characteristics, aetiology, the treatment offered in our setting, and factors associated with portal hypertension at a tertiary-level hospital, in Tanzania. Methodology A prospective cross-sectional observational single hospital-based study was conducted at MNH, from May 2021 to April 2022. A minimum of 152 subjects were required with an error of less than 5% and a study power of 80% at a 95% confidence interval. A structured questionnaire was used to collect data. Ethical clearance was obtained from the MUHAS/MNH IRB. Results A total of 154 eligible participants consented and participated in this study. The mean age of participants was 42 ± 15.8 years (range 2–87). Most of the study participants were males 64.9% with a male-to-female (M: F) ratio of 1.8:1. Vomiting blood was the common symptom among the study participants 51.3%. Schistosomiasis 53.9% and viral infection 26.6% were the common etiologies followed by alcohol abuse 7.8%. Most were medically treated at 89.61% followed by radiological treatment at 8.44% while only 1.95% of patients received surgical treatment. There was a significant association between the grade of oesophagal varices and bleeding consequences (p-value

Abstract Background In Tanzania, triphasic abdominal Computed Tomography (CT) is a more accessible and non-invasive alternative for diagnosing esophageal varices, though its accuracy has not been thoroughly evaluated, therefore this study aimed to determine the diagnostic accuracy of triphasic abdominal CT in detecting esophageal varices using esophagogastroduodenoscopy (OGD) as the gold standard among patients with upper gastrointestinal bleeding at Muhimbili National Hospital (MNH). Methods This cross-sectional study was conducted at MNH from January 2021 to May 2023. We sampled upper gastrointestinal bleeding patients who underwent both OGD and triphasic abdominal CT using non-probability consecutive sampling. The sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), and accuracy of triphasic abdominal CT were assessed against OGD findings. Results In a study of 200 participants, esophageal varices were detected in 54% by OGD and 53.5% by CT. We observed 105 true positives, 2 false positives, 90 true negatives, and 3 false negatives. Triphasic abdominal CT demonstrated a sensitivity of 97.2%, specificity of 97.8%, PPV of 98.1%, NPV of 96.8%, and an accuracy of 97.5%. Extraluminal findings included portal venous thrombosis in (22%), splenic collateral (51.5%), ascites (32%), hepatocellular carcinoma (13%), and periportal fibrosis (32%). Conclusion Triphasic abdominal Computed Tomography can be used as a reliable and non-invasive alternative modality for diagnosing and screening esophageal varices in resource-limited settings.

Background: Current guidelines advise that patients diagnosed with liver cirrhosis undergo screening through upper gastrointestinal endoscopy to detect esophageal varices (EV). Prophylactic measures should be taken for those with large varices on diagnosis and during follow-up. However, this poses a dual challenge, both social and medical, as the number of cirrhotic patients rises while the availability of endoscopy units remains limited. Aims and Objectives: In this study, we aim to evaluate the diagnostic accuracy of the non-invasive predictors such as spleen size, platelet count (PC), and PC/spleen diameter (PC/SD) ratio for the diagnosis of EV. Materials and Methods: This hospital-based prospective observational study was done in the SDM College of Medical Sciences and Hospital, Dharwad, among 50 patients with cirrhosis of liver. Results: Among the 50 patients studied males pre-dominated the study with 80%. Out of the study population, 70% of the patients had varices. For a cutoff point of PC/SD ratio 916, the sensitivity was 71.42% and specificity was 93.3%. For a cutoff value of PC of 1.32 lakhs, the sensitivity was 71.42%, and the specificity was 73.3%. For a cutoff value of the longest SD of 12.40 cm, the sensitivity was 94.30%, and specificity was 33.3%. Conclusion: These non-invasive predictors can be useful screening tools for the diagnosis of EV. These can be effective for the initiation of prophylactic treatment when the endoscopy facility is not available.

Background: Portal hypertensive enteropathy (PHE) is a small-bowel lesion observed in patients with portal hypertension. The clinical significance of endoscopic findings in PHE remains unclear. We aimed to clarify the clinical significance and predictive factors of capsule endoscopic findings in patients with PHE based on long-term outcomes. Methods: This retrospective study enrolled 55 patients with PHE (33 males and 22 females; median age, 64 years; range, 23–87) followed for > 3 years using capsule endoscopy (CE) between February 2009 and May 2023. We evaluated the clinical factors affecting PHE exacerbations and the effects of PHE exacerbations on gastrointestinal bleeding by comparing exacerbated and unchanged PHE groups. Results: Overall, 3 (5%) patients showed improvement, 33 (60%) remained unchanged, and 19 (35%) showed exacerbation on follow-up CE. In the exacerbated group, the rates of worsened fibrosis-4 index, exacerbated esophageal varices, and exacerbated portal hypertensive gastropathy were significantly higher than those in the unchanged group (21%, 32%, and 42% vs. 3%, 6%, and 12%, respectively; P < 0.05), and the rate of splenectomy was significantly lower in the exacerbated group than in the unchanged group (5% vs. 39%, respectively; P < 0.01). In multivariate analysis, exacerbation of esophageal varices and absence of splenectomy were significantly associated with PHE exacerbation. The rate of gastrointestinal bleeding after follow-up CE was significantly high in the exacerbated group (log-rank, P = 0.037). Conclusions: Exacerbation of esophageal varices and splenectomy were significantly associated with exacerbation of PHE. Exacerbated PHE requires specific attention to prevent gastrointestinal bleeding. [ABSTRACT FROM AUTHOR]

Endoscopic ultrasound (EUS)-guided vascular interventions were first reported in 2000 in a study that evaluated the utility of EUS in sclerotherapy of esophageal varices. Currently, gastric variceal therapy and portosystemic pressure gradient (PPG) measurements are the most widely utilized applications. Ectopic variceal obliteration, splenic artery embolization, aneurysm/pseudoaneurysm treatment, portal venous sampling, and portosystemic shunt creation using EUS are some of the other emerging interventions. Since the release of the American Gastroenterological Association (AGA)'s commentary in 2023, which primarily endorses EUS-guided gastric variceal therapy and EUS-PPG measurement, several new studies have been published supporting the use of EUS for various vascular conditions. In this review, we present the recent advances in this field, critically appraising new studies and trials. [ABSTRACT FROM AUTHOR]

Background: In Tanzania, triphasic abdominal Computed Tomography (CT) is a more accessible and non-invasive alternative for diagnosing esophageal varices, though its accuracy has not been thoroughly evaluated, therefore this study aimed to determine the diagnostic accuracy of triphasic abdominal CT in detecting esophageal varices using esophagogastroduodenoscopy (OGD) as the gold standard among patients with upper gastrointestinal bleeding at Muhimbili National Hospital (MNH). Methods: This cross-sectional study was conducted at MNH from January 2021 to May 2023. We sampled upper gastrointestinal bleeding patients who underwent both OGD and triphasic abdominal CT using non-probability consecutive sampling. The sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), and accuracy of triphasic abdominal CT were assessed against OGD findings. Results: In a study of 200 participants, esophageal varices were detected in 54% by OGD and 53.5% by CT. We observed 105 true positives, 2 false positives, 90 true negatives, and 3 false negatives. Triphasic abdominal CT demonstrated a sensitivity of 97.2%, specificity of 97.8%, PPV of 98.1%, NPV of 96.8%, and an accuracy of 97.5%. Extraluminal findings included portal venous thrombosis in (22%), splenic collateral (51.5%), ascites (32%), hepatocellular carcinoma (13%), and periportal fibrosis (32%). Conclusion: Triphasic abdominal Computed Tomography can be used as a reliable and non-invasive alternative modality for diagnosing and screening esophageal varices in resource-limited settings. [ABSTRACT FROM AUTHOR]

Background: Portal hypertension is a common diagnosis in Sub-Saharan African countries, with the majority of patients presenting late. This study aimed to understand Clinical characteristics, aetiology, the treatment offered in our setting, and factors associated with portal hypertension at a tertiary-level hospital, in Tanzania. Methodology: A prospective cross-sectional observational single hospital-based study was conducted at MNH, from May 2021 to April 2022. A minimum of 152 subjects were required with an error of less than 5% and a study power of 80% at a 95% confidence interval. A structured questionnaire was used to collect data. Ethical clearance was obtained from the MUHAS/MNH IRB. Results: A total of 154 eligible participants consented and participated in this study. The mean age of participants was 42 ± 15.8 years (range 2–87). Most of the study participants were males 64.9% with a male-to-female (M: F) ratio of 1.8:1. Vomiting blood was the common symptom among the study participants 51.3%. Schistosomiasis 53.9% and viral infection 26.6% were the common etiologies followed by alcohol abuse 7.8%. Most were medically treated at 89.61% followed by radiological treatment at 8.44% while only 1.95% of patients received surgical treatment. There was a significant association between the grade of oesophagal varices and bleeding consequences (p-value < 0.01). Conclusion: The majority of patients were medically treated while patients who require surgical care are unable to assess it. We recommend the establishment of a transplant services program to counteract the unmet need and more retrospective research toward policy establishment. [ABSTRACT FROM AUTHOR]

Objectives: The application of rifaximin, a non‐absorbable antibiotic, in hepatic encephalopathy (HE) has been well established; however, its effect on other complications in cirrhotic patients with previous gastroesophageal variceal bleeding (GEVB) remains unclear. Therefore, we performed a pilot randomized controlled trial aiming to evaluate the impact of rifaximin on cirrhosis‐related complications and changes in gastric microbiota. Methods: Eighty cirrhotic patients who received prophylactic endoscopic treatment for variceal rebleeding were randomly assigned to the control or rifaximin treatment group (rifaximin 400 mg twice daily for 8 weeks). Primary outcome was the total liver‐related score, consisting of changes in cirrhosis‐related complications including rebleeding, ascites, HE and portal vein thrombosis (PVT). The 16S rDNA sequencing analysis was conducted with gastric lavage fluid samples for the analysis of gastric microbiota. Results: During the 8‐week follow‐up, the total liver‐related score decreased significantly upon rifaximin therapy (−0.35 ± 0.14 vs 0.05 ± 0.14, p = 0.0465) as well as serum C‐reactive protein (CRP) (p = 0.019) and interleukin‐8 (p = 0.025) compared with the control group. The rate of PVT recanalization was significantly higher in the rifaximin group (p = 0.012). Prominent difference in gastric microbiota between the two groups was observed, and the rifaximin group had a higher abundance of several taxa which were dysregulated in the progression of cirrhosis. CRP was correlated with several taxa including Alphaproteobacteria, Rhizobiales and Collinsella. Conclusions: Rifaximin may improve cirrhosis‐related complications, including PVT, in patients with previous GEVB through anti‐inflammatory and microbiota‐modulating functions. Trial registration number: NCT02991612. [ABSTRACT FROM AUTHOR]

Objective: To explore the risk factors of portal vein thrombosis and treatment of backdoor hypertension in patients with esophageal and gastric varices. Methods: In tively, 102 patients from January 2019, all patients underwent endoscopic treatment with oesophageal and gastric varices, with portal venous thrombosis group (n=48 cases) and non-portal vein thrombosis (54 cases),compared with the two groups of laboratory examination, general clinical data, imaging examination results, and multifactor Logistic regression analysis was used to determine the risk factors of esophageal and gastric venous thrombosis. According to whether the patient has portal hypertension gastric disease aggravation after treatment. 102 patients were divided into portal hypertension plus restructuring and no portal hypertension and aggravation, and the general data and laboratory examination results of the two groups were compared.Multivariate Logistic regression analysis identified the risk factors for endoscopic treatment of posterior artery hypertension gastric disease aggravation. Results: The proportion of endoscopic esophageal varicose portal vein thrombosis was 47.06% (48/102). Univariate analysis showed that splenectomy history of portal vein thrombosis, gastric sclerosis injection, PLT, FIB, D2, internal diameter of portal vein, spleen length, spleen thickness, and splenic vein diameter without portal vein thrombosis (P＜0.05); multifactor Logistic regression analysis showed that the history of splenectomy, D-dimer, PLT, splenic thickness, and enlarged splenic vein diameter were the risk factors for portal vein thrombosis in patients with cirrhosis (P＜0.05). The proportion of endoscopic treatment for backdoor hypertension gastric disease aggravation was 29.41% (30/102). The results of the univariate analysis showed that, Portal hypertensive gastric disease and esophageal gastric Pux grade, Child-Pugh grade, Hp infection, portal vein flow history, portal vein trunk diameter and splenic vein diameter (P＜0.05); The multivariate Logistic regression analysis showed that, Severe esophageal varicose veins, Child-Pugh grade C, Hp infection, and history of portal vein disconnection were the risk factors for endoscopic treatment of posterior artery hypertension in cirrhosis (P＜0.05). Conclusion: A history of splenectomy, D-dimer, PLT, splenic thickness, and elevated splenic vein diameter are the risk factors for portal vein thrombosis of esophageal and gastric varices, severe, Child-Pugh grade C, Hp infection, and a history of portal vein rupture are the risk factors for the aggravation of portal hypertensive gastric disease after endoscopic treatment of liver cirrhosis. [ABSTRACT FROM AUTHOR]